Ch. 1 Introduction to Assessment Flashcards
What is the nursing process?
ADPIE! Assessment, diagnosis, plan, implement, evaluate
The nursing process is linear T or F
False
The first foundational step of the nursing process
Assessment!
Critical Thinking
- The process of intentional and reflective judgment about nursing problems, where the focus is on clinical decision-making, to provide safe and effective care.
- thinks beyond “what if”
Grounding/centering
focus and put energy back into the earth
Creating intentions
Getting focused and ready to see the patient
Preassessment phase includes
Heart centering, grounding/centering, and creating intention
Be CLEAR acronym
- Center yourself, Listen Wholeheartedly, Empathize, Attention, Respect
- Takes all 5 senses( verbal and non-verbal)
Holistic Care values
- Holistic philosophy, theories, and ethics
- Holistic nurse self-reflection, self-development and self-care
- Holistic Caring Process
- Holistic communication, therapeutic relationships, and healing environment and cultural care
- Holistic education and research
Characteristics of collaborative professional communication
- assertive communication> be assertive and direct
- rounding
- hand off report
- SBAR documentation
Each individual is unique T or F
True
The art of listening includes
- being client focused
- Body posture
- use all senses & active listening
- be careful not to act too quickly
- requires energy and concentration
- Art of not knowing> what isn’t being said?
Nonverbal Communication
No words just actions
- body posture
- facial expressions
- Gait/ movement
Health Assessment
A systematic method of collecting and analyzing data for the purpose of planning client-centered care
Assessment begins…
- at the first moment, the nurse meets the client
- first impressions
Head-to-toe approach
starts at head and neck and progresses down the body, examining the feet last
Why learn assessments?
- health assessment is a comprehensive assessment of the physical, mental spiritual, socioeconomic, and cultural status of an individual
- focuses on the functional abilities and physical responses to illness another structure
- assessment= painting a picture
Components of a health assessment
- Health history
- Physical examination
- Documentation of data
health history
data gathered about the clients health history, health conditions and diseases, family health history, lifestyle and risk appraisal, and life stress review
Physical examination
a systematic approach, same order each time. Head-to-toe approach
Documentation of data
Data collected from health assessments must be documented so that other healthcare providers can use the information
Subjective data
symptoms, what one can’t see
- what the client says
- cannot feel or see as a provider
Objective data
gathered data from the assessment
- what you can see ex. vital signs/ test data
Comprehensive Physical Assessment
Includes health history, interview, and a complete head-to-toe examination of every body system
Focused Assessment
An assessment that pertains to a particular topic, body part, or functional ability rather than overall health status and it adds to the database created by the comprehensive assessment
System-Specific Assessment
A focused assessment limited to one body system
ex. resp. distress/ cardiac
Ongoing assessment
An assessment that is performed as needed, after the initial database is completed and ideally at every interaction with the client
Purpose of physical examination
- to obtain baseline data
- identify nursing diagnoses, collaborative problems and wellness diagnoses
- monitor the status of a previously identified problem
-to screen for health promotion
Preparation for physical exam
- prepare the environment: make the patient comfortable
- Prepare the client: introduce yourself, explain what you will be doing
Positions during the physical examine
- Sitting
- fowlers
- prone
-supine - lateral(side laying)
- Sims(rectal exam)
- Lithotomy
Physical assessment techniques
- inspection
- palpation
- percussion
- Auscultation
Inspection
visual examinations, observing, inspecting the area, exposing only what you need to see, can use light instruments, DO NOT RUSH!!
Palpation
- Using touch to gather information
from different parts of hands to detect diff. characteristics - warm hands and short fingernails
- look for edemas and uncomfortabilities
Percussion
Tap skin striking surface with fingertips to vibrate underlying tissues and organs
- flatness= muscle or bone
- dullness= liver or heart
- resonance= hollow/ normal lung
- Hyper-resonance= lung with emphysema
- Tympany= stomach was gas(air)
Auscultation
- Listening to sounds that the body generates
- direct( w/ stethoscope) or indirect(w/o stethoscope)
- pitch, intensity, duration, quality
Components of a general survey
- Physical appearance and behavior
- Body Type and posture
- Gait and movement
- Speech
- Mental State and Affect
- Dress, grooming, and hygiene
- Vital signs
- Height and weight
Why is a general survey important?
- initial impressions gained from preliminary observations direct the nurse to further examination
- requires attention to detail
Physical appearance and behavior
- a variety of general observations about the patient; age, gender, race, and culture
- identify signs of distress
- does the patient appear healthy?
- note the color of skin, any lesions/ sunburn
Body Type and Posture
- observe body posture, and body symmetry, and observe for evidence of spinal deformities
- observe general impression of nutrition(well-nourished, overweight)
- Observe evidence of distress( sitting in tripod position, S.O.B.
- Do they assume a comfortable position
- Any guarding or splinting an area that may indicate pain
Gait and Movement
-Observe gait; balanced and smooth symmetry
- do arms swing freely?
- does the patient require assistive devices?
- Note ease of movement or struggle
- is their any limitations?
Speech
-Is there difficulty with speech?
- Listen for tone, pace, quality, vocabulary and sentence structure
- do they respond appropriately
- any hesitations or language challenges
Mental status and affect
- determine the level of consciousness
- orientation to time, place, person and situation
- is the client disorientated?
- what is the client’s mood?
Dress, grooming, and hygiene
- is the patient clean and well-groomed?
- Any odors?
- Are they dressed appropriately for the season?
Vital signs
- temperature
- blood pressure
- Pulse( heart rate)
- Respirations & pulse ox
- PAIN!
Normal values
newborn: 130 bpm, 30-60 resp., 80/40
Adult: 80bpm, 12-20 resp., <120/<80
Older Adult: 8, 12-20 resp., 120/80-160/95
Temperature
- Reflects the balance between the heat produced and the heat lost from the body and is measured in heat units called degrees
- F= 96.8-100.0 &C= 36-38
-Auxillary= 98.1 - oral= 99.1
- rectal= 100.1
Documenting temperature
- Always document the route
- single reading doesn’t always mean a fever
Febrile: fever afebrile: no fever
Measurement of temperature
- oral - Surface - Core measurement
- auxiliary - tympanic
- DOCUMENT CORRECTLY
important principle ofTympanic Measurement
- senses body heat in the form of infrared energy given off by a heat source in the ear canal
- Tug ear up and back(adults)
- down(children)
Heart rate(pulse)
- wave a blood created by contraction of the left ventricle of the heart
- peripheral: away from the heart
- Apical: central pulse located at apex of the heart
60-100bpm average
Pulse Locations
Radial: radial side of forearm at the wrist
Brachial(elbow) and Carotid(neck) arteries
Pulse characteristics
-rhythm: dysrhythmia or arrhythmia
- volume/ quality: weak/ strong
: Ease of access
- Elasticity of the arterial wall
Respirations
- counting the number of ventilatory cycles, inhalation, and exhalation, each minute
-inspiration: active process
-expiration: passive process
Respiration Characteristics
- Apnea: cessation of breathing
- Tachypnea: quick shallow breathing
- Bradypnea: abnormally slow breathing
-rate - rhythm
- volume/depth
- ease or effort
Blood pressure
the measure of the pressure exerted by the blood as it flows through the arteries
Systolic pressure
Pressure of the blood as a result of contraction of the ventricles, that is pressure at the height of the blood wave
- Top number
Diastolic pressure
Pressure when the ventricles are at rest, that is the lower pressure, present at all times within the arteries
-Bottom number
Pulse pressures
The difference between diastolic and systolic pressures
Factors that determine blood pressure
- Pumping ability of the heart
- Peripheral vascular resistance
- Blood viscosity
- blood volume
What can affect blood pressure
-age -race -nervous system
- medications -gender - caffeine
- crossed legs - body position
Orthostatic Blood Pressure
- Drop of 20mm/Hg or more systolic or a drop of 10 mm/Hg diastolic within 3 minutes after position change
- supine, sitting, standing
Maintaining healthy blood pressure
-eat a healthy diet with lots of fruits and veggies
- limit foods high in fat, salt, and sugar
- keep weight at a healthy level
- Don’t smoke or use nicotine
- limit caffeine and alcohol
Pulse Oximetry
- a noninvasive method of monitoring oxygenation with a device that measures oxygen saturation. The oximeter emits light and a photosensor is placed on the finger and measures the light passing through and calculates the oxygen saturation
- > 90% average
- > 95% expected
Describe the best practice approaches to physical assessments in pediatric patients
infants: exam room warm, assess vitals while sleeping
Toddlers: most comfortable on the lap of a parent, more like a game, make them feel comfortable, and lots of praising
preschoolers: Has more fear, demonstrate on doll first, make them feel comfortable, will withdraw if they feel threatened
School-age: Develop rapport, ask about school/activities, thinking is concrete, avoid using medical jargon
Adolescents: Provide privacy, demonstrate respect, expose only areas that are needed, allow opportunities for questions with out caregiver
Safety procedures for health assessment
- hand hygiene
- follow standard precautions
-identify patient - provide privacy
- position for safety and comfort
-utilize proper body mechanics - document properly
Standard precautions
-USE WITH ALL PATIENTS
- mask on properly
- donning and doffing properly
Ways to prevent falls in healthcare facilities
- admission assesses all patients for fall risks
- utilize standard fall risk assessment tools
- Purposely hourly rounding
- Identify modifiable risk factors
- place call light within reach
- keep floors dry and room free of clutter
Ways to prevent falls at home
